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ORIGINAL STATE OF CALIFORNIA <br /> Do not fi1d in <br /> + THE RESOURCES AGENCY <br /> Iih with DWit LiEPARTMENT OF WATER RESOUR-c5 No. 096684 <br /> , of intent No WATER WELL DRILLERS REPORT Strad \4ell No <br /> t„rL it Pennit No or Date a Other \V-Il No 01S+J�2E:/Z <br /> OWNER �y <br /> ti,i wino &(7 (13) WELL LOG Total deptlL./^5,ft Depth orf completed wel"�+ t <br /> \u ,e�s"� from ft to ft Form Aron�Mescnbe by a+lor LhAmLter Sve ur m itcrt,I) <br /> it% C f LFpf/ -7 <br /> 02) L ATX sP OF WELL - —C <br /> See instructions) <br /> EunntL LL�r+ ��_ IzAry 01%ner, \4cll N116er � + 2 <br /> L II iddre s if dr��n i ahovr <br /> 4 LJ + l <br /> Pi <br /> +w ns go Section <br /> DutuiLo En nn Cities roads, rnilr++nds fences etc - <br /> �J <br /> Ti <br /> (3) TYPE 0 `ti ORT <br /> New Well Deepening ❑ l f <br /> Reconstruction 0 <br /> 74e E: <br /> Reconditioning - + <br /> Honzontal Well [] - <br /> Destruction ❑ (Describe <br /> destruction materials and <br /> procedures in Item 12) - - <br /> (4) PROPOSED USE <br /> ` Domestic _ <br /> Irrigation 0 - <br /> �}• 1�f� ` Industrial ❑ - <br /> Y�L Test Well ❑ <br /> Stock ❑} - <br /> `J _Municipal ❑ <br /> E02WELL LOCATION SKETCH Other ❑ - <br /> 1E%T (El) GRAVEL PACK - <br /> Rot.ir% Reverse ❑ les g,-*---,4o ❑ <br /> thble C] <br /> Air ❑ Diameter of bore <br /> ,� - <br /> er ❑ BuLket ❑ Packed from - <br /> t7t CASING INSTALL (8) PERFORATIONS - <br /> el ❑ Pi, Caru.rete ❑ Tvpe of perforation or size of screen - <br /> From To Dla Gage or From To Slot - <br /> ft ft 11:1 Wall ft ft s ze - <br /> (9) WELL SEAL as surface sanitary seal. providedO Yes tT<n ❑ If yes to depth 5—_ft <br /> ere strata realed tgainht pulluho Ye t ❑ Intertiai __ rt <br /> Method of seahn• ' Work st,rted 19 Cnniplet I ., <br /> 110) W4TER LEVELS WELL DRIL R'S STkTE\IENT <br /> epth of first water if known ft This a.ell +aces r d rider my rurtadiction and this report is true to the best of m,1 <br /> aaduig level after well cnropletinn _ ft RtivuledKe an ere} ` �/ - J <br /> {11) WELL TESTS <br /> is well test made" Yes ❑ Nei if ves, by whom' (Well Driller) <br /> pe of test Pump ❑ Bailer 0 lar lift ❑ <br /> epth to triter at start of test it At end of test ft rPetfya'Brm,.grx6Q&" pan ) <br /> 4ugr _ al+nun after hours «aier temperature Address— Mer CA 91;Q80 <br /> Rtical anahsis madel Yes ❑ No W if yes, by whoina City , Zip <br /> ats electnc low inadea Yes ❑ No If %es ,[tach copy to this report License Ni� �--z Date of this report- -- <br /> 3S IREV 7 76, IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY N PIPL I D FORM <br />